HOW OBESE ARE WE REALLY?
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This article from the NZ Listener discusses the "obesity epidemic" and our unhealthy preoccupation with weight. Carry That Weight Are we really in the grip of an “obesity epidemic”? Can that many New Zealanders really be too big? In a society already very confused about body image and neurotic about personal health, maybe it’s time to weigh up the evidence behind these claims. By Cordelia Lockett There seems to be a new one each week. In the last three months alone, we have had a swathe of them reported: shoplifting, methamphetamine addiction, diabetes, meningitis, schizophrenia. Yes, we are in the midst of an epidemic of… epidemics. The most serious, costly and deadly of those, say health experts, is obesity. We are told that our ballooning weight leads to disease and early death and is costing millions in health spending. Competing headlines make a catastrophe of the situation, as we "declare war" on this "ticking time bomb". We are force-fed a monotonous mantra: we are fat and getting tatter, and we must lose weight. But is obesity as serious and prevalent as we are led to believe? It used to be that the words "obesity'' and "epidemic" were rarely used, let alone in the same sentence- Epidemics were rare plagues that swept unchecked through lands, causing misery. Surely, there were always fat people; obesity should be something exceptional. Is terrorising people about their weight helpful? Will bandying about the word "epidemic" just make us give up and dunk another doughnut? The lose-weight message doesn't apply to everyone (although dial doesn't stop weight-loss organisations advertising how "you can lose 10 percent of your body weight"), so how are normal or underweight people meant to respond? We are certainly more mixed up than ever about our bodies. Pick up any women's magazine: "Stars pile on the pounds," shrieks one, while asking, on the same cover, "Is Nicole too skinny?" Neurotically, our society manages to simultaneously glorify thinness, stigmatise fatness, promote overeating and endorse "quick fix" approaches to weight loss. Tried the "beach panic diet" yet? Is it any wonder that many young people and adults have stopped listening to their bodies' natural cues about when and what to eat? That they no longer eat normally and intuitively, but agonise over every eating decision? The two extremes of obesity and chronic dieting may be part of the same problem: a generally troubled relationship with food. Much of the obesity panic in New Zealand originates from two surveys: the Ministry of Health's 1997 National Nutrition Survey, comparing the prevalence of overweight and obesity in 1989 and 1997, which concluded that 52 percent of us were overweight or obese; and the just-released 2002 National Children's Nutrition Survey, which found that 31 percent of five to 14-year-olds were overweight or obese. Half of all adults? A third of all children? The figures seem hard to believe as you walk down the street. Where are all these people? The main tool used in these studies (and around the world) for classifying overweight and obesity is the Body Mass Index 9BMI). BMI is a simple height-weight ratio calculation (BMI = weight in kilograms divided by height in metres squared, or kg/m2, so if, for example, you are 1.70m and weigh 70kg, your BMI will be 24). But BMI thresholds haven't always been constant. Dr Paul Emsberger, associate professor of medicine at the Case Western Reserve University in Cleveland, Ohio, says that, in 1998 the National Institutes of Health lowered the overweight classification from a BMI of 27 to 25, in response to pressure from the World Health Organisation. A healthy person of 1.75m weighing 78kg would have had a normal weight in 1997, but be overweight in 1998, although their weight remained stable. (See box below for more detail.)
Shifting definitions aside, BMI is an extremely crude yardstick for determining weight-based health, according to Dr Michael Gard, senior lecturer in physical education at Charles Sturt University in New South Wales and author of a forthcoming book titled The Obesity Epidemic: science, ideology and morality. "BMI makes no concessions for things like bone density or muscularity. It doesn't take into account the physiology of a person," he says. He notes that BMI classifications are unhelpful for children and older people, and are culturally skewed. Auckland dietitian Jeni Pearce also thinks that too much emphasis
has been put on BMI, "BMI tells us nothing about body fat,
fat distribution, people's frame, fitness level, age- or gender.
We have this idea that if you're lean, you're healthy. But it's
much better to be a little overweight and fit than thin and unfit." THERE AREN'T A LOT of positives in "Nutrition and the Burden of Disease" - the 238-page report released by the Ministry of Health in August - which analyses current and projected obesity-related diseases. Obesity has been linked to an increased risk of heart disease, stroke, type 2 diabetes, some cancers and other conditions. The report estimates that high BMI accounted for 3154 deaths in 1997 (11 percent of all deaths) and 37,373 years of life lost. What's more, it says, these figures will grow along with the predicted increased average BMI. And the cost? A 1997 paper reporting six top obesity-related conditions estimated total health care costs of $135 million for one year. Who wouldn't be alarmed? But Dr Bruce Ross, principal lecturer in physical education at the Auckland College of Education, thinks that the links between obesity and disease have been overstated, and describes the ministry's document as "science fiction". He says that the increased mortality risk with higher BMI is "minimal". "There is an increase in diabetes in Western societies, but whether this is caused by obesity is open to question," he says, "There is an association. Diabetics have a tendency to be bigger, but plenty of people aren’t big and have type 2 diabetes. The increase may be due to more effective diagnosis. People are inclined to simplify - diabetes is more complex than people getting fat." Further complicating the issue is that some health consequences of being overweight, such as high blood pressure, may be due to weight fluctuation rather than weight itself. Repeated loss and regain of weight increases the risk of heart attacks, type 2 diabetes and deaths from heart disease. And although high BMI increases risk for some diseases, some studies have shown health benefits from being moderately overweight — for example, it is considered a protective factor against osteoporosis and some cancers, and for people with AIDS. Of course, being extremely overweight is a health risk. But by broadening the "at risk" category, the danger is that healthy people assume that they need to lose weight. If obesity is a disease, especially an epidemic, and more than half the population are defined as having the disease, it helps create a bigger market for the weight-loss industry, including drug companies. Auckland-based women's health researcher Gill Sanson: "There
is a history of large pharmaceutical companies hiring PR firms to
generate fear about a disease amongst a well population, in order
to create sales for their drugs." The author of The Osteoporosis
"Epidemic'': Well Women and the Marketing of Fear says, "Osteoporosis
is a good example of this, and it may he that the same tiling is
happening with obesity." In her book Dispensing with the Truth, US journalist Alicia Mundy describes the case of diet drug Fen-Phen, which was taken by about seven million Americans. In 1996, drug company Wyeth spent $US52 million on a campaign to promote the drug on the premise that 300,000 Americans were dying each year from the "obesity epidemic", deliberately redefining obesity as a disease in the process. (Millions of dollars in profit were predicted for Wyeth before it was forced to withdraw the drug in 1997, after it was linked with cases of lung and heart disease.) The US Center for Disease Control reports that between 1996 and 1998, nearly five million adults used prescription diet pills in the US, although a quarter of them were not overweight. However, with or without pharmaceutical assistance, restricting
food intake and increasing exercise is still no guarantee of success.
"Deliberate exercise can reduce weight, but only a small amount."
says Ross, "You can't turn a fat person into a thin person
long-term. Eighty-five to 95 percent of diets fail over the long
term- It's not a simple formula: energy in-energy out. The way we
metabolise food is incredibly complex. If we eat, our metabolism
increases and we burn energy. If we diet, this stops and we conserve
energy. Obese people don't burn energy as fast. And if anything,
they are often malnourished from chronic dieting." Disturbingly, unhealthy attitudes to food and weight seem to be developing earlier. Girls as young as five have been shown to be fat-conscious. In one Australian study, a. group of girls and boys aged seven to 12 were asked to select their ideal body size. Girls wanted a significantly smaller figure than their current one. Boys, on the other hand, did not. Researchers say that children are adopting their parents' attitudes of thin-ness as the ideal and dieting the norm. "Our culture tells us to be very afraid of food," says Jane Tyrer from Auckland's Eating Difficulties Education Network (EDEN). "Girls ring us up worried because they've put on two kilograms." Perhaps this isn't surprising, given the emphasis on early nutrition education in schools. Senior lecturer in physical education at Otago University Dr Lisette Burrows researched Year Four and Year Eight children's attitudes to health and fitness. Asked to draw pictures of what being healthy looked like, many drew scales and rulers. "There was an absolute equation that being healthy is not being fat," she says. "They were very clear on what was good food and bad food. But the 'don'ts' were stronger than the 'dos'. There was a real lack of pleasure associated with health and fitness. "We've produced a panic around childhood that is reproduced in the media and through all the agencies around kids. There's a surveillance of children — we monitor all their inputs and outputs - especially eating and exercise. We're always watching. But the kids soon learn to do it, too. It's fear-based - like a war." One Christchurch study showed that 72 percent of women reported wanting to weigh less, while only 35 percent were overweight for their height. Twenty-four percent of the women said that they were always or usually dieting. And although only a relatively small number of women are diagnosed with the eating disorder bulimia, preoccupations with food and weight and various purging techniques are widespread, even normal. (Think Bridget Jones-style obsessive dieting, weighing and recording.) As part of her research (to be published in the Journal of Health Psychology in July next year), Burns interviewed women who described practices such as taking diet pills, smoking, liposuction, excluding certain "bad'' foods from their diets (such as potatoes and bread), fasting, vomiting, exercising for up to 20 hours a week and misusing laxatives — all in the desperately ironic attempt to achieve a "healthy-looking" body. Eating-disorder statistics in New Zealand aren't readily available, but people working in the field say that the problems are increasing. "Anorexia athletica [extreme exercising] is definitely increasing," says Jeni Pearce. "There's also the weekend bulimic. She eats and exercises normally during the week and then goes crazy with food and alcohol at the weekend. Then she makes herself throw up to avoid putting on weight." Burns contends that official health-sector approaches implicate everyone in the same, potentially counter-productive, weight-control vigilance. "By emphasising external, quantifiable indices of health - like BMIs - we reinforce the perception of health and unintentionally endorse practices that sacrifice real health and well-being," She says that although the Ministry of Health's Healthy Eating, Healthy Action policy uses careful phrases such as "healthy weight-maintenance", the public perceives this as a lose-weight message in another guise. It inadvertently fails to take into account that many women already practise severe food restriction and other unhealthy weight-loss activities. Burns questions the need to focus on weight at all. Focusing on increasing physical activity and improving nutrition -- rather than weight reduction — may he a more responsible approach. Given dieting's high failure rate for sustained weight-loss, this may be a more realistic approach for the thousands of New Zealanders trying to lose weight. MICHAEL GARD has no ready answers to why we are getting heavier.
"The data supporting the idea that we're consuming more calories
isn't there. In fact, we're eating less," he says. So, it must
be lack of exercise, then? "There is no scientific evidence
of that, either. The literature is incredibly confused on this.
The long-term studies are non-existent. In terms of surveys of the
level of fitness of the population in the last 60 years, the authorities
have always been horrified. We're never satisfied with what we are. Gard is referring to the well-worn notion that the permissive society is responsible for its own moral and physical degeneration: the social-liberal agenda has removed old constraints, people have become slothful and gluttonous. From the "personal responsibility" standpoint, lax morals coupled with the increased availability of high-fat food are causing our swelling obesity figures. Certainly, it is acceptable to claim that society has become too accepting of fat people. In a presentation at the Childhood Obesity Symposium in September, Massey University's Professor John Birkbeck (also an adviser to Weight Watchers) suggested a combination of education, subversion and coercion to reduce obesity. Two specific strategies he suggested were weighing schoolchildren every year, then reporting those "outside defined limits", and making obesity antisocial. Jane Tyrer questions the basic assumptions of such an approach. "We live in the opposite of a fat-accepting culture," she says, "If we value body diversity, why are people so terrified of putting on weight and prepared to go to extreme lengths to avoid it?" Indeed, when newspaper columnists can blithely assert that, "The only reason diets fail is that fatties return to sloth and their disgusting eating habits after they've lost some weight" (Gordon McLauchlan, NZ Herald), bring overly tolerant of size doesn't really appear to be the problem. Furthermore, there is an often unspoken but subtly elitist aspect of fat fear and loathing: its socio-economic implications. A war on obesity might be, in some ways, a class war. Commentators from every side agree on the well-established link between obesity and poverty. The fattest of us are also the poorest. And obesity can be both a cause and a consequence of poverty. Because low socio-economic status contributes lo disease and low life expectancy, regardless of weight, this may also be influencing the statistics on weight-related disease. The Ministry of Health's 2002 National Children's Nutrition Survey of 3275 five to 14-year-old New Zealand children found that 31 percent were either overweight or obese, with rates highest for Pacific Island children, followed by Maori and then Pakeha children. But children living in poor areas and Maori and Pacific Island children were also less likely to have had something to eat at home before going lo school. Twenty-two percent of households reported not being able to always afford to eat properly, which rose to 36 percent of Maori and 53 percent of Pacific Island families. More than a third of households reported that the variety of food in their diet was limited by a lack of money. However, says Elaine Rush, associate professor of applied science
at the Auckland University of Technology, the figures for Pacific
Island and Maori children may have been overstated, and she cautions
against over-interpreting the results. The method used to define
overweight and obese in the survey came from a British statistician
who used longitudinal studies of children from six countries, but
with no Maori or Pacific Island participants. Rush says that Maori
and Pacific Island girls with the same BMI have less body fat than
their Pakeha counterparts, "We need more holistic ways of assessing
children's weight," she says. Even health professionals specialising in obesity are not immune from bias. A recent study found that obesity clinicians and researchers associated the stereotypes lazy, stupid and worthless with fat people. "The fact that even health professionals have the bias reinforces how incredibly pervasive and powerful the stigma of obesity is in our society," said the study's author, Yale University research scientist Dr Marlene Schwartz. So, are claims about an "obesity epidemic" - however well-intentioned — really the answer to this complex diet of public health policy, modern consumerism, economics and age-old prejudice? No, says Gard. "An epidemic says 'drop everything - we've got a health crisis'. But is it prudent to be bundling health money into an epidemic that is — at best - very controversial? We may be misdiagnosing a huge section of the population that isn't even unhealthy.'' IS THERE A BETTER WAY? EDEN advocates a whole-population health
message that can apply, regardless of size: ''Enjoy food. Eat when
you're hungry. Stop when you're full. Like your body. Eat a wide
range of foods that are nutritious and enjoyable. Do sustainable
and enjoyable exercise." Two Tales From The Scales THREE YEARS AGO, Aucklander Max*, then 35, joined a gym to get
fit and lose weight. At the initial assessment, he was bluntly told
he was obese. At 1.65m and 85kg, he had a BMI of 31 -just inside
the obesity range. What is it like to be told you are obese? "It
was intimidating and on balance, it was a demotivator. I felt despondent
- it's a depressing diagnosis." He says that for people with
low self-esteem (and many overweight people suffer from this), it
might make them give up. He did lose weight, but then stopped going
to the gym and put it back on. He says that health professionals
and fitness instructors should discuss with clients the gap between
the medical and popular understandings of obesity, because people
might be shocked to hear that they are obese when they feel they
are just overweight. LISTENER
NOVEMBER 29 2003 |
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Disturbed
eating habits at a young age are a major contributing factor in
the development of eating disorders later on, reports Maree Burns,
who, as part of a PhD at Auckland University, is researching the
relationship between current weight-focused public health messages
and eating-disorder behaviours. The current equation of slenderness
with health, she argues, is the problem, "It gives only the
appearance of health — a perception that may have little to
do with an individual's actual well-being. Unhealthy weight-management
practices remain hidden."
PEOPLE
LAUGH when Janeen Nowicki, at 105kg, tells them she's a fitness
instructor. It seems that fit and fat just don't compute. Nowicki,
43, of Wellington, is a big woman, but in an average week teaches
16 exercise classes - including step, pilates, kickboxing and yoga
- and goes to the gym five days out of seven. She has got textbook
cholesterol and blood pressure, a resting heart rate of 60-65 and
may be underselling herself when she describes her fitness as "above
average" (she has also taken part in many triathlons). With
a BMI of 35, she easily fits the widely used definition of obese.
Although she is "constantly watching" her diet, she has
found it difficult to lose weight, and is heavier than she was 10
years ago. Nowicki says that exercising in gyms can be intimidating
for fat people, but they feel comfortable in her classes, because
they think if she can do it, so can they.